Attitudes towards people who use substances: a survey of mental health clinicians from an urban hospital in British Columbia

Stigma and other barriers limit harm reduction practice integration by clinicians within acute psychiatric settings. The objective of our study was to explore mental health clinician attitudes towards substance use and associations with clinical experience and education level. The Brief Substance Abuse Attitudes Survey was completed among a convenience sample of mental health clinicians in Vancouver, British Columbia. Five predefined attitude subgroups were evaluated. Respondents’ attitudes towards substance use were associated with level of education on questions from two (non-stereotyping [p = 0.012] and treatment optimism [p = 0.008]) subscales. In pairwise comparisons, postgraduate education was associated with more positive attitudes towards relapse risk (p = 0.004) when compared to diploma-educated respondents. No significant associations were observed between years of clinical experience and participant responses. Our findings highlight important aspects of clinician attitudes that could improve harm reduction education and integration into clinical practice.


Introduction
North America is currently in the midst of an unprecedented opioid epidemic. The number of opioid-related deaths is rising steadily across Canada, with the highest mortality rate occurring in British Columbia [1]. Many individuals with opioid use present with several comorbidities including co-occurring mental illness and polysubstance use [2]. These factors contribute to several cross-cutting health and social challenges, often limiting treatment initiation and increasing opioid-related harms [3] Individuals with both psychiatric and substance use issues are at increased risk for drug-related death [4], especially following periods of abstinence and reduced tolerance, such as hospitalization [5]. Harm reduction interventions, such as take-home naloxone and supervised consumption sites, are important elements of care and are associated with a reduced risk of overdose death [6]. Despite a robust body of evidence supporting the public health benefit of harm reduction interventions [7], stigma and related barriers (e.g. discrimination, lack of knowledge) can limit their availability across the health system [8]. Existing research consistently reveals that health care professionals hold negative beliefs about people with substance use disorders [9], and these attitudes may worsen over time for dually diagnosed patients [10]. Unfortunately, these stigmatized perceptions, such as abuse of health system resources or failure to adhere to recommended care and treatment [11,12], often contribute to inequitable and poor provision of care including reduced access to harm reduction resources [13]. For example, in acute psychiatric settings addiction-related stigma among clinicians has been associated with poor harm reduction integration [14,15]. The acceptability of harm reduction approaches among clinicians is an important determinant of increased implementation of essential, evidence-based services to combat the ongoing opioid epidemic.
Given the disconnect between the scientific evidence for and the resistance to harm reduction among health care providers, it is critical to examine how clinician attitudes towards substance use influence the harm reduction best practices in psychiatric settings. The objective of our study was to explore mental health clinician attitudes towards substance use and associations with clinical experience and education level.

Methods
We conducted an online cross-sectional survey among a convenience sample (n = 71) of mental health clinicians (nurses, physicians and allied health) between May and June 2022 at a tertiary care hospital in Vancouver, British Columbia. Participants were recruited via email based on internal distribution lists and informed consent was obtained electronically. Eligible participants were employed fulltime, parttime or casual within the hospital and had at least one year of experience in an acute psychiatric setting. The survey included socio-demographic questions (gender, education, clinical experience) and the 25-item Brief Substance Abuse Attitudes Survey (BSAAS). The BSAAS [16] was derived from a 50-item instrument, the Substance Abuse Attitudes Survey, using a Likert-type response format ranging from 1 (strongly disagree) to 5 (strongly agree) to examine attitudes towards various aspects of drug and alcohol use and five predefined attitude subgroups were evaluated: permissiveness, non-stereotypes, treatment intervention, treatment optimism and non-moralism [17]. Chi-square test or Fisher's exact tests were used to examine the association between attitudes towards substance use and years of clinical experience and education level. Hochberg procedure [18] was applied to adjust p values for multiple comparisons. Statistical analyses were performed using SAS version 9.4. Ethics approval was obtained from the Providence Health Care/University of British Columbia Review Board.

Results
Among the 71 respondents who completed the survey, the majority identified as female (85%), were employed as nurses (48%), with bachelor's (44%) or master's (23%) level education and fewer than ten years of experience in their primary clinical role (71%) ( Table 1). Over half (60%) of respondents reported a high level of daily contact (> 71% of workload) with individuals who use substances, but low levels of comfort in providing care and treatment (Table 1).
Respondents' attitudes and views towards substance use were associated with level of education on questions from two subgroups, non-stereotyping (p = 0.012) and treatment optimism (p = 0.008) ( Table 2). In pairwise comparisons within the treatment optimism subgroup, postgraduate education was associated with more positive attitudes towards relapse risk (p = 0.004) when compared to diploma-educated respondents. In contrast, no pairwise effect was observed between education type with respect to propensity for hard drug use (p = 0.310) within the non-stereotyping subgroup. No significant associations were demonstrated between years of clinical experience and attitudes towards substance use ( Table 2).

Discussion
We found that postgraduate education contributes to less stereotyping attitudes and a higher level of treatment optimism when working with individuals with substance use or dependence. These findings highlight important dimensions of clinician attitudes (e.g. beliefs) that could improve harm reduction education and integration into clinical practice.
Prior research has identified that negative attitudes are consistently viewed as barriers to evidence-based harm reduction practices [19]. Even though combating stigma has been a focus of public health professionals, there are few interventions that demonstrate measurable improvements towards stigmatizing beliefs among health care providers [20]. Livingston and colleagues [21] in a systematic review identified that on-the-job education, which includes contact-based training, has demonstrated improvements in reducing stigma but the evidence base remains equivocal. Our results add to the literature by demonstrating a significant effect between less stigmatizing views and individuals with postgraduate education. This finding is important and may reflect the focus on anti-discriminatory and anti-oppressive practices within postgraduate pedagogy which challenges personal values and social norms regarding substance use [22].
We observed no associations between years of experience and clinician attitudes in our sample. This nonsignificant finding was in contrast to our hypothesis and existing literature which suggests that more experience and therefore increased contact with individuals who use substances fosters more positive attitudes [23]; however, this effect appears to be stronger for the general public [24] than health care providers. Moreover,        this null finding highlights opportunities to provide workplace education for clinicians across all stages of their career, regardless of experience level. Further research is required to understand elements of education and training that are associated with more positive attitudes towards and improved care for individuals who use substances. The limitations of this study include a low proportion of non-nursing providers, generalizability to other regions or settings and the cross-sectional survey design with assessments of attitudes at a single time-point.